Please complete this application form if you are applying for one of our posted internship roles.

Contact Information

First name:

Last name:

Street 1:

Street 2:

City:

State:

* Zip: *

Home phone:

Cell phone:

Email address:

What internship position are you applying for? (Please write the title of the position below.)

Student Information

Date of birth:

School:

Is this internship required by your school or class? If yes, please provide name of school.

Education

How many course credits have you completed? For example: 60 credits

Availability

Sun

Mon

Tue

Wed

Thu

Fri

Sat

From:

To:

My availability is:

From:

to:

How many hours do you need to complete your internship requirements?

Internship Details

Please indicate the time frame in which your internship hours need to be completed.

Summer (May-August), Fall Semester, Spring Semester or Full Academic Year (September-May)

Skills

Please list any skills pertinent to the internship role.

Please list any special skills, certifications or interests: Example: Proficient in Excel/ Word.

Experience

Why do you want to complete your internship at Lowell General Hospital? What do you feel you can contribute to the role?

Additional Information

In a few sentences help us get to know you better. How would you describe yourself?

Reference Section

1

2

First name:

Last name:

Street 1:

Street 2:

City:

State:

Zip:

Home phone:

Work phone:

Cell phone:

Email address:

Relationship:

Emergency Contact

First name:

Last name:

Home phone:

Cell phone:

Email address:

Relationship:

I Agree

I understand and agree that submitting this application form does not automatically give me an internship role at Lowell General Hospital

I Agree